History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: May, 1935 Vancouver Medical Association May 31, 1935

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 The BULLETIN,
i
OF THE
VANCOUVER MED
ASSOCIATION
Vol. XL
MAY,  193 5
In This Issue:
ANNUAL MEETING   -   NEWS and NOTES
RETIRING PRESIDENT'S ADDRESS
THE SURGERY OF THE PRESACRAL NERVE SB2E
FINEST QUALITY
Halibut Liver
Oil
Biologically tested, imported from Great
Britain. Guaranteed to contain at least
50,000 International Vitamin A Units per
gram.
This fine produce is unsurpassed and is at
your disposal for prescription either in bulk
or collapsible capsules at approximately half
the price of other similar products.
Capsules containing 3 minims (equivalent in
Vitamin A content to 4 teaspoonsf ul of Cod
Liver Oil) 50 in box for $1.00.
Obtainable at all
VANCOUVER  DRUG CO.  STORES
Western Wholesale Drug Co.
(1928) Limited
456 BROADWAY WEST
VANCOUVER   -   BRITISH COLUMBIA mil
THE     VANCOUVER     MEDICAL     ASSOCIATION
BULLETIN
^Published ^Monthly under the nAnspices of the Vancouver tTtledical ^Association in the
Interests of the ^Medical "Profession.
Offices:
203 Medical Dental Building, Georgia Street, Vancouver, B. C.
Editorial Board:
Dr. J. H. MacDermot
Dr. M. McC. Baird Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address
Vol. XL MAY,  193 5 No. 8
OFFICERS   193 5-1936
Dr. C H. Vrooman Dr. A. C Frost
President Past President
Dr. G. H. Clement Dr. W. T. Lockhart
Hon. Secretary Hon. Treasurer
Additional Members of Executive—Dr. T. R. B. Nelles, Dr. F. N. Robertson
TRUSTEES
Dr. W. D. Brydone-Jack Dr. J. A. Gillespie Dr. F. Brodie
Auditors: Messrs. Shaw, Salter & Plommer
SECTIONS
Clinical Section
Dr. J. R. Neilson    —  Chairman
Dr. Roy Huggard    Secretary
Eye, Ear, Nose and Throat
Dr. E. E. Day  —    Chairman
Dr. H. R. Mustard   -  Secretary
Paediatric Section
Dr. G. A. Lamont       Chairman
Dr. J. R. Davies   Secretary
Cancer Section
Dr. J. W. Thomson  -—-    Chairman
Dr. Roy Huggard        Secretary
STANDING COMMITTEES
Library Summer School
Dr. G. E. Kidd Dinner Dr- H- A" DesBrisay
Dr. W. K. Burwell „    T T Dr. H. R. Mustard
Dr. C A. Ryan Dr. Lavell Leeson Dr. j. W. Thomson
Dr. W.D.Keith Dr. J. G. Harrison Dr. C. E. Brown
„    T,   .   „ Dr. A. Lowrie t~.     t t-  w/.titco
Dr. H. A. Rawlings Dr. J. E. Walker
Dr. W. A. Bagnall Dr. J. W. Arbuckle
Publications Credentials
Dr. J. H. MacDermot Dr. H. A. Spohn
Dr. Murray Baird Dr. J. W. Thomson
Dr. D. E. H. Cleveland Dr. W. L. Graham
V. O. N. Advisory Board
Dr I T Day Rep' to B' C' Me^'ca^ Assn-
Dr. W. H. Hatfield Dr. W. C Walsh
Dr. A. B. Schinbein
Sickness and Benevolent Fund — The President — The Trustees
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PUBLIC HEALTH
BIOLOGICAL PRODUCTS
Diphtheria Antitoxin
Diphtheria Toxin for Schick Test
Diphtheria Toxoid  (Anatoxine-Ramon)
Scarlet Fever Antitoxin
Scarlet Fever Toxin for Dick Test
Scarlet Fever Toxin
Tetanus Antitoxin
Anti-Meningitis Serum
Anti-Pneumococcic Serum   (Type 1)
Anti-Anthrax Serum
Normal Horse Serum
Smallpox Vaccine
Typhoid Vaccine
Typhoid-Paratyphoid Vaccine
Pertussis Vaccine
Rabies Vaccine   (Semple Method)
INSULIN
Price List Upon Request
Connaught Laboratories
University of Toronto
TORONTO 5 - CANADA
Depot for British Columbia
Macdonald's Prescriptions Limited
Medical-Dental Building, Vancouver, B. C.  For the rest of your natural life
I sentence you to the hypodermic needlel
THIS is the verdict feared by every diabetic.  It is the sentence which the
physician should avoid wherever possible.
For proper indications and in emergencies, there is of course no complete
substitute for insulin. But many diabetics thrive on oral treatment with
Pancrepatine, which contains the hormone of pancreas and liver ACTIVE
BY MOUTH.
Pancrepatine spares insulin and never causes hypoglycemic shock. It spares
the patient the discomfort of the hypodermic needle. It reduces urinary
sugar—frequently clears it up entirely. Also controls polydipsia and polyuria.
Prescribe 2 to 4 globules of Pancrepatine t.i.d. Supplied in bottles of 100
hormone-active globules protected against ferment action.
PANCREPATINE
ORAL TREATMENT  FOR DIABETES
Obtainable from B.  C. Drugs  Limited, Vancouver;  Georgia  Pharmacy,  Vancouver; McGill & Orme, Victoria.
ANGLO-FRENCH DRUG CO., MONTREAL EDITOR'S PAGE
The Draft Act dealing with Health Insurance has been completed, and
distributed to various organisations and individuals who will be especially
interested. There is no doubt that at an early date an opportunity will be
given to the medical profession to discuss it.
It is largely a skeleton Act: i.e., it consists chiefly of broad enunciation
of principles. Details of administration and application will, we understand, be left to be formulated later in the form of regulations; so that if
the Act appears to be sketchy, it is not really so. But it is easier to alter and
amend regulations than to amend the provisions laid down in the Act, and
as this legislation is in many respects quite in the experimental stage, this
is, we feel, a wise method to follow.
It is too soon yet to comment on this bill. It will be carefully scrutinized
by the Committee appointed by the Council of the College of Physicians
and Surgeons, and it will be laid open for the examination and consideration
of all concerned; but in the meantime, there are certain things that we feel
should be kept in mind. First, there will be a natural tendency, especially
with as individualistic a creature as the medical man, to feel that our own
corns are the tenderest, and are in especial danger of injury. So one section
of the profession may feel that some other is receiving undue consideration,
and that its own members are suffering unduly. We do not think there is
any danger of this. At first, it will be impossible to avoid some difficulties,
and there may be some inequalities—but if we are all together, and unselfishly considering the good of the whole, we shall have no trouble in meeting
and solving the problems that may arise. And secondly, we must keep an
open mind, and not be too much influenced by the traditions under which
medicine has been labouring (we use the word advisedly) for so long. Times
are changing, says the Latin poet, and we change with them—and a reactionary attitude will help us not a whit, while it will delay, but only for a
while, the inevitable social changes which are even now overdue. A flexible
attitude need not be lacking in firmness—ask any competent physical-
culturist—and rigidity invites fracture and irreparable damage, where
flexibility would lead to a good result. It is not a case, we think, of resignedly
accepting the change while reserving the right to harbour secretly a feeling
of resentment. The medical profession should lead in this matter, should
recognise the need for radical change, and the injustice and social menace
of the present state of affairs; and should welcome reform, and throw its
whole weight behind it. By so doing, we shall gain immeasurably. We shall
convince society of our honesty and sincerity; we shall assume the position
of leadership to which our qualifications as a profession entitle us, and we
shall maintain and enhance our dignity, and the respect in which we are
held by the community. We believe that the profession will accept this
position of responsibility, and be true to its greater and more worthy traditions of service: a word much exploited and much abused, but still one of
the greatest words in the language.
And lastly, we must remember that there is really only one consideration, and it is the consideration that animates our profession at bottom: the
truest welfare of the sick. We know better than anyone in what the real
welfare of the sick man consists; we know what constitutes real medical
care; and we should be ready, not only to insist on good medical care, but
to detect any tendency to failure, and to a compromise which, while apparently more economical and more immediately expedient, it yet unwise and
ultimately  injurious.    Given  sincerely  and  honestly,   and  without  self-
Pagc 16>
i
w seeking, we cannot doubt that those who are sponsoring this Act will
gladly and willingly listen to our advice and suggestions, since it is their
earnest desire to frame an Act which will do the most good possible, and
the least harm, to all concerned in its operation.
The Bulletin takes this opportunity of congratulating District No.
3's new members of Council, Drs. W. E. Ainley and L. H. Appleby. One's
only regret, and we are sure it is shared by these two gentlemen, is that
all the candidates could not have been elected. Dr. J. A. Gillespie, the
third candidate for election, has deserved well of the Vancouver medical
profession. We think it, is safe to say that Dr. Gillespie enjoys the respect
and esteem of every medical man who knows him, and their gratitude as
well. Perhaps only those who have worked with him on the various committees on which he has served know just how much his work has meant
to his brethren. Now that he has got rid of this particular burden of work,
he will be available for something else—gratitude having been defined as
"a lively sense of favours to come."
Another man that will not be a member this year is Dr. J. G. McKay of
New Westminster, and we hereby acknowledge, on behalf of the whole
profession, the debt we owe to Dr. McKay, who has been a member for a
long time, and has well earned a rest. Dr. McKay has done invaluable work
for his profession. Well-known in every circle, persona grata with the
leaders of all political parties, shrewd and sagacious, he has, year in and year
out, made his influence felt at all times; and with the wisdom born of long
experience, he has done much to guide and direct our destinies. In the long
years during which we resisted the onslaught of quackery and the untrained
practitioners of various healing cults, his leadership was of inestimable
value—and it was never possible to stampede "Jim" McKay. Undoubtedly,
his advice and counsel will still be available if needed—and meantime we
think him for all he has done.
NEWS AND NOTES
That members of the medical profession are regarded as "easy marks"
is an old story. Salesmen of stocks and bonds of the variety which have
to seek a market among individual speculators, and beggars of all descriptions, put doctors in the first column of their "sucker list." The "boiler-
room racket"—to the uninitiated, selling tickets by telephone to "charity"
concerts, dances, etc.—is one of those which has been worked most successfully in the last two or three years, and as usual the doctors have been
prominent among those whose charitable instincts have thus been exploited.
The following suggestion is made to our readers: when you are called
up and asked to buy tickets for a dance, concert or other such affair in the
interests of some charity or other, or to pay from one^to ten dollars for space
in an advertising booklet to be placed in churches of all denominations at
Easter or Christmas, in which the church may have printed its special order
of service—it may be all right, but make a note of the name, address and
telephone number of the person calling, the time and place of the charity
function and the organization to be benefitted. Then call up the Welfare
Federation Headquarters (Bay. 3 5 31) and ask for information as to whether
this is a genuine appeal or not. After that, you can decide for yourself what
to do. Not only will you protect yourself against exploitation, but you will
help to hasten the time when this type of "racket" is ended in Vancouver.
Do not be deceived if the person telephoning you assures you that you do
Page 166 not need to investigate, and that a license has been granted from City Hall.
On at least one occasion the writer found by investigation that this statement was false.
Dr. J. R. Neilson is the proud, very proud, father of an 8 l/2 -pound
red-headed son, born during the Annual Meeting on Tuesday, April 23 rd,
1935.
Editor V. M. A. Bulletin:
Dear Sir,—At the annual meeting you expressed a wish for some froth
to balance the weighty contents of the Bulletin. The chairman of the
Library Committee indicated his inability to select a suitable crest for the
Association.   These two circumstances suggest something.
Why not open a competition (limited to one paragraph) and offering
a prize of a half dozen golf balls (new, not hammered out of shape by G.
Seldon) for the most suitable design.
In the hope that this may meet with your approval, I hasten to submit
my own conception, which, owing to my inability to draw, I must perforce
describe in mere words as:
An open book (Bible) gules on a field argent surmounted by a skull
couchant and supported by an obstetric forceps rampant, with the motto
"Ab ovo, per vitam, ad mortem."
This is sufficiently indicative of the life of a medical practitioner, and
so far as I know is not registered at the College of Heralds and wotild not
expose the Association to danger of a lawsuit.
Anonymous.
The Summer School Committee gave an interim report at the Annual
Meeting, foreshadowing a course of lectures that we can none of us afford
to miss. This is no figure of speech either; the calibre of the men who are
coming, and the reports we have had on them, are of the first order.
Programmes of the meeting can be obtained from the Library, and the
actual subjects to be spoken on will be found printed in these, but our
readers will be interested possibly in a brief sketch of the speakers and the
school as a whole.
Dr. William Dock, of San Francisco, is an authority on cardiovascular
diseases and his four papers deal with this and renal and blood disorders.
Dr. Arthur Steindler, who deals with Diseases of Joints, Fascias and
Fractures, was chosen after careful consultation with our orthopaedists, who
unanimously recommended him as their choice, so that we may be assured
of his excellence.
Dr. Verne Hunt spent quite a while with the Mayo Clinic, is an authority
on genito-urinary surgery, as well as general surgery, and is an outstanding
speaker.
Dr. John Budd has been spoken of by many as the coming leader in
pathology on the North American continent, and one of his papers looks
particularly attractive, "The Relationship Between Pathologist and
Clinician."
We come next to two men whom we know perhaps better from a personal point of view.
Dr. Charles Hunter of Winnipeg, Emeritus Professor of Medicine in
Manitoba University, is an old and tried friend of ours; a man whose
addresses here have been uniformly attractive and significant. Nobody who
has heard Dr. Hunter talk needs any eulogy from us to make him want to
Page 167
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1L hear him again, and we feel that his name alone would make this programme
worth while.
Lastly, Dr. Perry McCullagh. He was once an interne at the Vancouver
General Hospital, and so is well known to many of us. He has been Crile's
right-hand man for some years, and is an authority on endocrinology. There
can hardly be any subject of more importance today.
A lay speaker is also a member of the team: Mr. H. N. Brocklesby, Chief
Chemist at the Fisheries Experimental Station, Prince Rupert. This gentleman is an authority on the vitamin content of the Pacific fish, and has been
doing outstanding work on this. He is giving two lectures.
Davis & Geek, the well-known surgical suture makers, are shewing
some films that have never before been shewn in Vancouver.
And last, but not least, there will be a golf tournament, and it is rather
significant that this is followed in the evening by a paper on Renal Failure,
and another on Minor Ailments.
To all our friends in B. C, and in the States to the south of us, a most
cordial invitation is extended to come to a meeting that we are confident
will be one of the best ever held.
ANNUAL MEETING
The Annual Meeting of the Vancouver Medical Association, held on
April 23rd, 193 5, marked the end of another year of considerable activity
for the Vancouver Medical Association. The attendance was unusually
good for an annual meeting, but we surest to members who miss these
meetines that they also miss a °-ood deal of valuable and interesting information. The present membership of the Association stands at 245, and as Dr.
Ewing, the Secretary, remarked, it is very discreditable that our average
attendance is only about one-quarter of this number.
An interesting feature was the presentation to the Association of the
Doomsday Book, which will now record the salient facts regarding our
lives and careers for the benefit of future generations of members. As far
as possible, details of deceased members will also be included in this volume.
Our Honorary Treasurer, Dr. Lockhart, gave his report. Treasurers'
reports are usually uninteresting and dull hearing to all except those few
gifted souls who love to discuss figures, but Dr. Lockhart has succeeded
year after year in winning the interest of members as he reads his report,
since we cannot but feel that he himself has a genuine interest in his task
and a devotion for which we must all be grateful. The financial statement
was very satisfactory, showing the Society to be solvent and possessed of an
adequate margin. Several items are of especial interest, for example, the
maternity relief fund. From August, 193 3, to* April, 1935, some six hundred and eleven cases have been notified and about three hundred and forty
of these have been paid for.
The affairs of the Summer School are in excellent order and a balance of
$2,317.00 shows a good state of health.
Dr. E. Brodie reported for the Trustees. The Sickness and Benevolent
Fund has been of great benefit, especially lately, and the money disbursed
has helped greatly to avoid trouble and to give relief. The bond investments
of the Association, as one might expect in this year of the depression, are
not in a very happy condition, and Dr. Brodie gave full details of them.
The interest on these bonds is largely in default, and we can only hope that
as times improve the payments will be resumed.   Dr. Brodie suggested on
Page 168 behalf of the Trustees that there be a resumption of payments to the Sickness and Benevolent Fund.
Dr. G. E. Kidd then reported for the Library Committee, showing a
satisfactory state of affairs excepting in so far as the perennial problem of
conscienceless borrowers still harasses the Committee. The annual plea for
better behaviour was made.
Dr. G. S. Gordon's collection of books, which had been loaned to the
Library, has now been presented permanently, and the thanks of the Association are due to Dr. Gordon.
The Publications Committee presented a report showing a balance of
$285.50 to the good.
Dr. R. A. Simpson, for the Credentials Committee, reported the acceptance by the Committee of fifteen new members during the year. Nine of
these were admitted to membership by the members on regular ballot and
six are waiting election in the Fall.
Dr. Lockhart then reported for the Relief Administration Committee,
giving a brief history of the dealings carried on with the City since the
inception of our arrangement with them for the payment of relief cases.
He told us that the experience of the Committee has convinced them that
a great majority of medical men are fair and play the game honestly, but
that some ten per cent of the men definitely try to take advantage and
require very strict censorship of their accounts. This is greatly to be
deplored, especially in view of the fact that this inexcusable weakness on
the part of a small minority of the profession is handicapping us in our
dealings with compensation boards, civic committees, and will be one of
the chief difficulties in negotiations concerning health insurance
$43,500.00 has been collected for relief cases from the City and Province
in fifteen months. Of this amount $40,925 has been paid to medical men,
showing a commendably small overhead charge. As a matter of fact, with
salary, rent and expenses, the total overhead has amounted to some $1,421.
The average payment to doctors is 2 6 % of the amount rendered. The Committee does not regard this as satisfactory and is attempting to secure a
higher rate of payment.
Dr. Isabel Day then reported for the Victorian Order of Nurses.
Dr. J. E. Walker gave an interim report on the 193 5 Summer School
and a brief summary of the speakers and programme appears elsewhere in
this number. Dr. Wallace Wilson reported as delegate to the B. C. Medical
Association. He referred to the steps being taken for a closer union with
the Canadian Medical Association, also the advisability of an Executive
Secretary who should be also connected with the College of Physicians and
Surgeons of B. C.
Dr. Pedlow reported on the revision of by-laws and his report showed
that an immense amount of work has been done on this. A copy of the
revisions suggested is posted in the Library and all men are urged to read
them and be prepared to discuss them at a later date.
The question of the appointment of a historian of the Association was
brought up by Dr. Pedlow. Much of the history of our older men of intense
interest has necessarily been lost.   Without further delay steps should b
taken to secure data for publication and record.
Dr. Pedlow gave notice of motion that the proposed revision of by-laws
as posted be adopted by the Vancouver Medical Association.
The various sections reported activities for the past year.
Election of officers then ensued and the following officers appointed:
Page 169 I,
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President—Dr. C. H. Vrooman.
Vice-President—Dr. W. T. Ewing.
Hon. Treasurer—Dr. W. T. Lockhart.
Hon. Secretary—Dr. G. H. Clement.
Editor—Dr. J. H. MacDermot.
Trustees—Dr. W. D. Brydone-Jack, Dr. J. A. Gillespie, Dr. F. Brodie.
We cannot but congratulate the Association on the choice of the new
president, Dr. C. H. Vrooman, and feel that the affairs of the Association
will be in excellent hands. The new president has more than earned this
honour from the Association. For many years he has done yeoman service on
various committees, notably on the Relief Committee, of which he is still
a member. He has been President of the B. C. Medical Association and has
had wide experience in administrative affairs. His views are sane and command the respect of all who know him.
Dr. Frost closed the meeting with a valedictory address, which we publish elsewhere in this issue.
RETIRING PRESIDENT'S ADDRESS
Members of the Vancouver Medical Association:
Tonight we have come to another milestone in the history of our
Medical Association in Vancouver; and it makes us pause and consider
whence we have come and whither we go?
It has been my great privilege to have been President of this Association
during the past year, and I wish at this point to thank you for the honour
thus conferred upon me.
What has been accomplished has been made possible by the splendid
help and co-operation of the officers of the Executive, and the chairmen
of the various committees, who have given me, at all times, their unfailing
support and most helpful assistance, for which I proffer my most sincere
thanks.
In looking back over the past year, I feel that we have made real progress
along several lines.
One of these is Preventive Medicine. Dr. Vaughan and Dr. Gordon
of Chicago and Detroit addressed our Association at a special meeting in
the early summer on the subject, and outlined the progress being made in
the larger cities of the East.
They stressed the fact that if Preventive Medicine is to be of any practical value to the community, there must be greater co-operation between
the public health bodies and the medical profession. Something we can all
do to assist in this work is for each of us to take an active interest in some
form of public health service—such as the Health Bureau of the Board of
Trade, which I think is deserving of our unqualified support; or the Greater
Vancouver Health League; or any other branch of social service that promotes Preventive Medicine ideas.
A committee of Preventive Medicine was formed with Dr. Amyot as
chairman, and under his able leadership there is being obtained a real cooperation between the medical practitioners and the public health bodies.
Arrangements are being completed to give radio talks and illustrated lectures
to educate the public in regard to diphtheria toxoid, vaccination, etc., and
all matters pertaining to Preventive Medicine.
Cancer.—I am pleased to hear that the B. C. Medical Association is
working in conjunction with the Vancouver Medical Association towards
the establishment of a free Radium Cancer Clinic.
Page 170
m The world-wide cancer campaign of King George should be a great
help in educating the public along these lines, especially in our own province, which is far behind the other provinces in the free treatment of cancer.
Tuberculosis.—I would, when speaking of these preventive measures
in Medicine, like to congratulate the Vancouver Public Health Institute of
Diseases of the Chest, for the splendid work they are doing in educating the
public regarding tuberculosis, its prevention and treatment.
Relief Committee.—A Relief Committee, with Dr. Lockhart as Chairman, was appointed to interview the City Council regarding remuneration
for relief cases, with the result that all doctors attending such cases have
been paid. The fees, as you know, are not large, but it is interesting to note
that, to date, $40,92 5 has been distributed; and I feel that the sincere thanks
of the whole Association are due Dr. Lockhart and his committee for their
untiring efforts in connection with this work.
Retail Credit Grantors Association.—Another thing I would like to refer
to is the Retail Credit Grantors Association. You have all heard of this
many times, and I believe about one-third of our Association are already
members, so that it is unnecessary to review its merits again. However, I
may state that a special medical division with an advisory medical committee
has now been formed to deal with our business and accounts exclusively.
It has been of great assistance in the collection of accounts from patients
who are able to pay but who, owing to other obligations, have neglected
their medical bills.
Therefore to those of you who have not associated yourselves with this
firm, I would strongly urge the advantage of so doing.
There is just one danger in this forced collection of bills, and that is
the danger of making our profession too mercenary.
We, as medical men, owe a duty to humanity, and just because a person
cannot pay does not excuse us from giving medical service.
This is not the object of our association with the Retail Credit Grantors.
To my way of thinking, the idea is to make those pay who can—not to
demand the pound of flesh from those who are utterly unable to make
payments of any kind.
A matter was brought to my notice the other day by one of our charitable institutions; a girl was taken suddenly ill and the secretary telephoned several physicians who, when they found it was a non-pay case,
refused to go. It is my sincere hope that in trying to get our just dues
we do not lose sight of the high ideals of service that have always been
associated with the medical profession.
The Summer School Committee, with Dr. Spohn as Chairman and Dr.
Mustard as secretary, ably carried through a very fine programme; and it
was very gratifying to know that there were more attending physicians
from outside points than ever before.
Our Library Committee, headed by Dr. Kidd, placed many new
books on our shelves, and it is here that I would like to mention the very
generous donation of Dr. F. J. Nicholson of $250.00 for library requirements. It is to be hoped that this will inspire others to do likewise. I have
also the pleasure of announcing the gift to the Library of a portrait of Dr.
Kocher by Dr. A. L. Lynch, for which I offer him our sincere thanks.
I feel that I cannot leave the subject of the Library without making
mention of our very efficient librarian, Miss Firmin. Her knowledge of the
library itself, her thorough understanding of all matters pertaining to the
Association's affairs, and her unfailing willingness to co-operate and assist
one and all members at all times, is well known by every member of our
Page 171 rmr.i.
Society and I feel that I am expressing the sentiments of the entire organization when I extend to her our sincerest thanks and appreciation.
Health Insurance.—Many issues will have to be faced in the coming
year, one of which, and a very important one, will be Health Insurance.
It is still a very much disputed subject, and there is certain to be a
great deal of discussion and argument on the matter.
Personally, I feel that it is very desirable, and if the details can be
adjusted to be fair to both the doctors and the laity, it is to be hoped that it
will be a step in the right direction in this time of depression and economic
chaos.
It is only by each and every one of us giving thought to the subject
and bringing in any helpful suggestions that may occur to us, that we shall
be able to aid our incoming officers and ourselves in this matter.
Clinical Section.—Our Clinical Section this year has done splendid work
under the able chairmanship of Dr. Wilfred Graham, with Dr. Neilson as
secretary, and the meetings have been extremely interesting, instructive and
well attended.
It is along this clinical line that I would like to see specialized study
groups formed in our Association. There are many young men, and old
ones too, who, I am sure, would gladly attend these classes, and deeply
appreciate any opportunity to listen to the special subject in which he might
be particularly interested. Most men hope at some time to specialize in
some branch of the profession. If they knew that at a study group some
specialist was giving a clinic, a lecture or just an informal talk along his
special line, I am sure that they would be eager to attend.
To many of us, in these times of depression, who are unable to get away
to brush up on our work, it would be a great boon; and to all of us it would
act as an incentive and inspiration to acquire by study and reading all the
new ideas and methods that are continually being developed by our rapidly
growing profession,
I feel that it would raise the standard of the profession in the city, and
tend towards a more closely knit bond of friendship and fraternity between
members of our Association.
In closing, I wish to thank you all for your tolerance of my shortcomings (and they have been many), and for your kindly commendation
of any small part I have had in the year's work.
I again thank the officers of the Executive for the staunch support they
have accorded me throughout the year.
May I beg of the incoming Executive the same sterling allegiance to
the new President, Dr. Vrooman.
It is my sincere hope that our Association shall be a power in our city
for the promotion not only of health but of all the higher ideals of life—
Honour and Charity and Sincerity—and that, first and foremost, we practice
these among ourselves.
THE SURGERY OF THE PRESACRAL NERVE
By W. F. Emmons, M.D., Ph.D.
The presacral nerve in the nomenclature of today is the name applied
to a mass of nerve fibres and ganglion cells lying immediately anterior and
in juxtaposition to the terminal portion of the abdominal aorta. It extends
downwards for several centimetres in the fork of the bifurcation of this
Paper presented before The Vancouver Medical Association, April 2nd, 193 5.
Page 172 great vessel into the two common iliac arteries. As certain critical writers
have pointed out, the term "presacral nerve" as applied to this structure is
merely of topographical significance. It also carries an erroneous connotation, in that many nerves and anastomosing branches as well as ganglion
cells go to form the components of this structure as a whole. Such an
anatomical arrangement elsewhere in the body would be known as a plexus.
Therefore it has been argued that a more suitable name would be that suggested by Hovelacque, the "superior hypogastric plexus," in contradistinction to the two inferior hypogastric plexuses still farther down on its course.
However, for the sake of the older terminology which is now so familiar,
this structure will be referred to here as the presacral nerve.
From the historical point of view clinical attention was first directed
toward the sympathetic supply of the pelvic contents as early as 1898 when
Jaboulay in France attempted to relieve pain in the pelvic viscera, particularly of vesical origin, by section of the sacral sympathetic chain. A year
later Ruggi in Italy suggested paralysing the utero-ovarian plexus to reheve
pain of gynaecological origin. Both these investigators, in spite of several
attempts, were only moderately successful with their cases, and their operations fell by the wayside, and remained there for some years before the
subject was again taken up. In 1925 Leriche applied his technique of periarterial sympathectomy to the internal iliac arteries for the purpose of
relieving the pain of dysmenorrhoea. From this time onwards the interference with the sympathetic supply to the pelvis has been accepted as
having a definite place in the therapeutics of certain painful gynaecological
conditions and it remained only for the technique of the procedure to be
improved. Cotte, after using Leriche's method for a time, soon found that
equally satisfactory results were obtainable by section of the much more
accessible structure, the superior hypogastric plexus or presacral nerve. The
advantage of Cotte's operation was quickly realized and its popularity
rapidly grew so that cases of its use have mounted to considerable numbers
from which critical conclusions may now be drawn.
Before going into the clinical aspects of the subject, it will be well to
review for a moment the anatomical relations and physiological functions
of the presacral nerve. Up till recently the anatomy of the nerve has been
of academic interest only, and when discussed it was on purely theoretical
grounds. With the advent of a practical application of this knowledge a
renewed interest has been aroused in the details of the ramifications of the
nerve, making them of a much more definite character. This recent work
is largely due to the labours of Prof. Leriche of the school of Lyon. It began
with the hope of relieving the pain of functional dysmenorrhoea, but has
been extended in its scope to cases suffering from cancer of the uterus, the
cystalgias, pruritus vulvae, etc.
Elaut studied the anatomy of the nerve in 5 0 dissections. He describes
it as being subject to wide variations but conforming in a general way to a
fixed type. Thus it resembles in shape an elongated triangle whose apex
points toward the diaphragm. The angles at the base lie between 1.0 to 3.5
cm. apart and represent the commencement of the hypogastric nerves which
are the bilateral extension of the central structure above. The area enclosed
bv this trianele is traversed b- the anastomosing branches of the plexus.
Secondary connections enter the mass from other regions such as the inferior
mesenteric plexus and the 4th and 5 th lumbar ean^lia bilaterally. For
surgical purposes this area has been named the interiliac trigone. It is
delimited above by a horizontal line at the level of the sacral promontory
extending laterally to meet both common iliac arteries.  Its other two sides
Page 173
1M are formed by the arteries themselves as they converge at the apex. Its
vertical diameter is approximately 6 cm. Attention is to be drawn to the
presence of the middle sacral artery lying in the centre of the trigone bisecting it longitudinally. This has been mistaken for the nerve and utmost care
must be exercised to avoid wounding the artery.
The hypogastric plexus as it descends upon the lower aorta lies in intimate contact with the wall of the latter, except for a thin layer of connective tissue interposed between the two. They can be easily separated at
this point, but as the nerve leaves the aorta to cross the left common iliac
vein the adhesions are still more easily freed, due to a more fragile form of
connective tissue bed. The whole is covered by the posterior parietal peritoneum, which is found to come away easily without disturbing the setting
of the nerve owing to an infiltration of the loose network with fatty tissue.
The origin of the nerve has been variously dealt with by different writers.
According to Learmonth, who has epitomized these descriptions in conjunction with his own elaborate dissections, the nerve appears to arise from three
roots. There is "a right lateral, left lateral and a middle root. On the right
side the lateral root begins about 1.5 cm. below the right renal artery, by
the union of three or four nerve bundles of constant origin. The most
internal arises from a nervous loop which crosses the aorta below the origin
of the superior mesenteric artery. The middle springs from the semi-lunar
ganglion or cceliac plexus; the external from the right periarterial renal
plexus. As this passes downwards it is joined on its outer side by two
branches arising from the 1st and 2nd lumbar ganglia respectively. Most
of the fibres of the original root pass to the intermesenteric and inferior
mesenteric plexuses; the remainder, with the branches from the lumbar
ganglia, continue their downward course to reach the interval between the
common iliac arteries as the right lateral root of the presacral nerve. The
eft lateral root has a similar origin. The middle root is the prolongation
downward of the intermesenteric plexuses, after they have supplied the
roots of origin of the inferior mesenteric nerves; these mesenteric plexuses
establish wide connections with the cceliac, semilunar and aortico-renal
ganglia." The united nerve is stated to be a more or less solid structure in
about 20% of cases and of plexiform arrangement in 80%. Learmonth's
dissections proved that the nerve was plexiform in 20% and solid in the
remainder. Such is a general survey of the sympathetic distribution as far
as the hypogastric ganglia. At this point it is joined by fibres from the sacral
or parasympathetic system. From these ganglia are distributed branches
to the ureters, bladder and uterosacral ligaments. From the latter, according
to Fontaine and Herrmann, there is a further cell station and plexus on each
side of the body of the uterus and in the broad ligament. These nerve fibres
are destined mainly for the uterine musculature. Adson describes the
sympathetic supply of the ovary as derived from the ovarian plexus which
arises from the intermesenteric and renal plexuses and follows the ovarian
artery throughout its course. The Fallopian tube is also innervated from
this source.
Kuntz as one of the most reliable authorities upon the subject describes
the ovary as being innervated by the ovarian plexus which forms a mesh-
work of fibres around the ovarian artery and vein. This plexus receives
fibres from the aortic and renal plexuses and superior mesenteric and cceliac
ganglia. Its fibres are distributed to the ovary and Fallopian tube, and also
communicate with the uterus through the uterine plexus. The uterus,
however, derives its main supply from the uterine plexus and indirectly from
the vaginal plexus. The Fallopian tube occupies a mid-position and receives
re 174 fibres from both the ovarian plexus and the utero-vaginal plexus. The
vaginal plexus is composed chiefly of parasympathetic fibres derived from
the sacral outflow but also contains sympathetic elements descending
through the presacral nerve.
The physiological action of this sympathetic nervous supply is as elsewhere antagonistic to the parasympathetic supply to the respective pelvic
organs. Too dogmatic statements as regards function are to be avoided as
yet, for the reason that so much variation is found, not only between
different species but in the same species depending on whether an organ is
in a state of tone or flaccidity. For example, the sympathetic supply through
the presacral nerve to the urinary bladder has been described for simplicity
as the "filling system" of the bladder, while its parasympathetic supply in
like manner as the "emptying system." Thus stimulation of the cut end
of the presacral nerve, distally, would cause inhibition of tone in the bladder
wall and an increased tone of the internal sphincter. Learmonth presents a
detailed list of the actions of the presacral nerve on the bladder, on the human
subject as follows:
1. Inhibition of the expulsive muscles of the bladder.
2. Motor to the muscle around the ureterovesical orifice.
3. Motor to the muscle of the trigone.
4. Motor to the internal sphincter.
5. Motor to the smooth muscle of the prostate gland.
6. Motor to the smooth muscle of the seminal vesicles and ejaculatory
ducts.
7. Afferent, conveying impressions of distension of the bladder.
8. Afferent, conveying impressions of pain on spasmodic contractions.
9. Vaso-constrictor to the vessels of the bladder.
McCrea and MacDonald criticize the above tabulation in that it suggests
a fixed and constant function which they have found is not always the case.
They admit that there is some authority for every item hut that modification of each statement is also required. Thus according to the experimental
work of Elliott on animals of different species, stimulation of the presacral
nerve in the ferret causes a generalized contraction of the bladder. However,
in the cat, pig and monkey the same stimulation causes a general relaxation.
In the dog and rabbit a contraction of a narrow portion of the base of the
bladder was noted. Also in the dog, Griffiths found that a contracted bladder relaxed and that a flaccid bladder contracted when the sympathetic
supply was stimulated. It is therefore evident that the function of this
nerve is complex and the generally accepted conception that the sympathetics
are inhibitory and the para-sympathetics excitor to the bladder may be only
partially correct. However, Learmonth based his findings on more than
hypothetical grounds, and what is more he performed his experiments on
the "animal" with which he was most concerned, namely man. Not only
did he secure the permission of his patients to stimulate the cut ends of
their presacral nerves at time of operation but in order to check on the
sensory effects of distension of the bladder, submitted himself to pressure
variations and other experiments, thus gaining a first hand knowledge on
the human subject which few others have been able to do. On account of
the direct method he used, some of his experiments are worthy of recounting here. Under spinal anaesthesia and at open operation the presacral nerve
was isolated. A competent urologist co-operated in the experiment by
observing any changes in the appearance of the bladder through a cystoscope throughout the entire period of the operation. The patient was fully
conscious and responding, and so was able to co-operate in the sensory tests
Page 17S
1 carried out. It is obvious, from the experimental point of view, what ideal
conditions Learmonth had arranged for his work. It is also remarkable how
co-operative most patients were in accepting spinal anaesthesia in order to
have cerebration intact; also to permit the slight but definite delay in the
operating time to allow scientific work of this nature to be done. Observations were carried out upon six cases. By the use of spinal anaesthesia the
cord was paralysed only to the height of the 6th and 7th D. segments, and
the anaesthesia was confined to the nerves and cells below this level, in contrast to a generalized anaesthesia such as ether where there is a general
dulling of all nervous tissues throughout the body. On account of the pre-
and post-ganglionic arrangement of the autonomic nerve fibres the pelvic
viscera still retained their peripheral ganglionic control even under spinal
anaesthesia, though the afferent impulses were of course nullified below the
highest segment of the cord affected.
Learmonth set about definite experiments in order to trace the fibres
causing specific effects. First there was stimulation of the whole or intact
presacral nerve. The effects were found to be similar to those obtained by
stimulating the peripheral cut end. The orifices of the ureters tightened to
pin-point dimensions, lasting for a short time after the passing of the
stimulus. Sometimes a spurt of urine would precede this closure. The
internal sphincter contracted promptly on the cystoscope and the whole
bladder floor tightened slightly. The musculature of the prostate and
seminal vesicles contracted, as evidenced by the appearance of seminal and
prostatic fluid in the posterior urethra. The vessels in the neighboring parts
of the bladder wall blanched as elsewhere on stimulation of other sympathetic nerves. Upon stimulation of one hypogastric nerve similar effects
were noted but these were confined to the ipsilateral side. There appeared
to be no reflex effect upon the bladder, the co-called Sokownin reflex in
animals. In two cases the partially filled bladder was connected to a manometer in order to determine the presence of a "filling" effect when the presacral nerve was stimulated, i.e., relaxation of musculature of the vesicle
wall. Owing to the difficulties of such an experimental set-up in the operating room the results were somewhat indeterminate, though there was a
slight dilation in both instances. Conversely I can remember another piece
of research by the same experimenter (which is as yet unpublished). A
contraction of the bladder took place as indicated on the manometer when
the sacral nerves of the cauda equina were stimulated electrically at open
operation on the sacral portion of the spinal cord. These experiments tend
to confirm not only the presence of a filling but also of an emptying action
in the sympathetic and parasympathetic supply of the bladder. One further point in corroboration of these findings was proved on a normal bladder
by the injection of adrenalin after connecting the partially filled viscus to
a manometer. This chemical stimulation was tantamount to a direct electrical stimulation of the presacral supply. A marked relaxation of the
bladder wall occurred and was maintained for several minutes. Then a
desire to void raised the intravesical pressure abruptly and terminated the
experiment.
When this scientific data is used clinically it is found to be applicable in
three types of bladder dysfunction: paresis of the bladder, vesical pain and
in spasmodic conditions of the vesical neck. In paresis of the bladder it must
be remembered that the trouble may be due to either one of the two controlling influences. A normally acting bladder represents a perfect balance
between the filling nerves or sympathetic fibres and the emptying nerves in
the sacral or parasympathetic outflow.  The stimuli arriving through these
Page 176 routes may be augmented or decreased pari passu, in which case there is no
upset in the resulting balance between the two. But if for any reason either
system varies in the intensity of its effect without a corresponding variation
in its antagonist, an imbalance immediately results. Thus a frequency can
be engendered in two distinct ways; a paresis of the sympathetic or a conceivable hyperexcitability of the parasympathetic. Conversely the so called
"cord bladder" can be accounted for in the same manner. It is essential to
determine the basal pathology in all such cases before subjecting them to
sympathectomy alone as the panacea for all bladder troubles. This truth
was forcibly demonstrated in a case referred to my care in which there was
paresis of the bladder of such degree as to necessitate catheterization for
periods of considerable duration at a time. Upon careful neurological
examination a diminution in cutaneous sensitivity was discovered in th
region of the penis, anus and scrotum, which coupled with the history of
a fall in a sitting posture pointed to a lesion of the cauda. Since operation,
when the caudal fibres were freed up from a condition of chronic cystic
arachnoiditis, all symptoms have cleared up including the bladder paresis.
Presacral neurectomy might have had considerable effect upon the bladder
symptoms by restoring the balance above mentioned, but how much better
it is to have restored the full power of the impaired parasympathetic pathways than to equalize the balance by paralysing a normal sympathetic supply
which had been converted into a preponderating influence due to the paresis
of its antagonist. The result would be expected to be more permanent,
because of the operation being restorative rather than a deletion of a counteracting force. This operation was done two and one-half years ago with
a perfect result to date. I wish to emphasize this point as a word of caution
to those who may be tempted to regard the presacral operation as a cure-all
for vesical trouble and perhaps be prone to blame the operation when it has
been misapplied or too much has been expected from it.
Learmonth cites another similar case in point where the presacral technique was the operation of election, thus demonstrating the fine discrimination that must be exercised in the selection of these cases. As first assistant to
Learmonth at that time, I well remember the brilliant result obtained, the
more remarkable because of its early place in this type of work. It was a
lad of 8 years who at the age of 3 had suffered from a form of paralysis
offecting the bladder and his lower extremities. After a time the paralysis
of the legs cleared up but that of the bladder persisted. At the time he
came to the Mayo Clinic he had been catheterized three times every day for
the previous five years. It was considered that a permanent degeneration had
taken place in the parasympathetic supply and therefore there was no hope
of augmenting the intensity of these stimuli. The only alternative under
such conditions was to so weaken the sympathetic system that the desired
balance would be restored. The result of presacral neurectomy was all that
could be hoped for and the boy from then on could completely empty his
bladder not only immediately after but when last heard from a year postoperatively.
The second type of case where the operation applies is where the
vesical pain is the predominating factor, and involves chiefly the sympathetic
fibres. It has been shown that the presacral nerve carries definite viscera
sensations (afferent fibres). The parasympathetic also is responsible for a
part of this function and it is a debatable question to what extent eithe
plays a role. Quite apart from these afferent fibres and beyond all question
of doubt is the function of the sympathetic in the control of the vaso-motor
phenomena as elsewhere in the body.  It is generally conceded that much of
Page 177 ft I M
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the palliative effect ot sympathectomy in dealing with the cystalgias is due
to the vasodilatation produced. In chronic interstitial cystitis there is no
doubt but that a combined effect takes place. Fewer painful stimuli caused
by the spasmodic contractions are conveyed to the brain. These seem to
travel by way of the sympathetic route especially. But the healing effect
of the increased blood supply cannot be overlooked and may abort the painful irritation and contractions in their site of origin. Ordinary sensation
from the bladder is not interfered with by the operation.
There are some significant features regarding the post-operative treatment in these bladder cases. The guiding principle is to avoid any stretching
of the bladder wall in a viscus that is endeavouring to recover from just
such a condition. A permanent catheter is therefore advisable so long as the
patient is confined to bed, on account of the added difficulty in voiding while
in the prone position. Again, since it is the object of the operation to tip
the physiological balance in favour of the parasympathetic effect, the power
of this system can be enhanced by the use of acetylcholine hydrobromide, a
drug exhibiting a pressor effect on muscle fibres innervated by parasympathetic nerves just as adrenalin acts as the counterpart of the sympathetic
system. Intramuscular injections of acetycholine twice daily should be continued for at least two weeks following the removal of the catheter. Occasional catheterization is advisable to check on any amounts of residual urine
that might appear from time to time. In spite of all precautions, it has
occasionally been necessary to weaken the internal sphincter by the punch
operation in order to render its power compatible with the force in the
detrusor muscle. In concluding this section dealing with the relationship
of the presacral nerve to the urinary bladder it should be recalled that
stimulation of the nerve causes contraction of the musculature of the prostate, seminal vesicles and ejaculatory ducts; conversely it would be expected
that paralysis of the nerves would delete this action. Since the nerve by its
section at operation is paralysed, the ejaculatory function in the male is also
paralysed though there is found to be no interference in any way with the
sexual act or the attainment of the oreasm.
Dysfunction of the large bowel.—The condition of megacolon is classified in two types. First, Hirschsprung's disease, which is synonymous with
congenital megacolon of neurogenic origin; and second, acquired megacolon
due to chronic obstructive causes, which are largely of mechanical nature.
Hirschsprung's disease is chiefly met with in children. Its cause is unknown
though sometimes explained by the phrase "constitutionally inferior types,"
in which there is some dysfunction of the neuromuscular mechanism resulting in an improper balance between the filling and emptying apparatus of
the large bowel. The disease was first described by Hirschsprung in 1886,
as a congenital, severe dilation of the colon with thickening of the tunica
muscularis. 'The acquired type resembles the congenital form in many ways,
such as the thickening of the muscle layers, etc., but differs in that it is not
present from birth. It is always associated with a demonstrable mechanical
obstruction of a chronic nature. For this reason there is hypertrophy of the
muscular tunics as opposed to thinning of these layers in more acute forms
of obstruction. The symptoms in either condition vaj— from severe con-
stioation to complete obstruction. The secondary symptoms ranee from a
toxic condition of .eeneral malaise and emaciation to marked abdominal distention with even cardiac and respiratory embarrassment at times. The less
severe cases are relatively well controlled by medical measures, mild cathartics and mineral oil combined with suitable dietary measures. It may be
necessary to supplement this treatment with such medication as eserine and
Page 17Z acetylcholine, drugs which stimulate the parasympathetic system and tend
to inhibit the sympathetic. Enemata are of course advisable to assist in the
evacuation of the bowel at the same time as reinforcing the tone of the
musculature by other means. Surgical measures have also been applied,
including colostomy, enterostomy and appendicostomy with only moderate
degrees of success and a mortality of about 25%. It is only after medical
measures have been tried without success that surgery should be resorted to.
With the success attending the more modern surgical procedures upon the
sympathetic supply of the bowel, only a reasonable trial of medical thera-
peusis is warranted. Wade, in 1927, removed the 1st and 2nd lumbar ganglia
on the left side and showed there was a definite effect on the colon when the
sympathetic supply was interfered with. The following year Judd and
Adson extended the operation to the 2nd and 3rd and 4th lumbar ganglia,
and included both sides. They felt their results were not only more effective
but also applied in more severe cases. Rauhin and Learmonth showed that
most of the sympathetic fibres affecting the colon passed through the
superior hypogastric plexus and advanced this type of operation. In order
to be sure all connections are broken Adson now does a very wide sympathectomy embodying all preceding technique and claims a high degree of
efficiency. He not only adheres to his former operation of the bilateral
lumbar sympathectomy as well as presacral neurectomy but extends his
dissection into the intermesenteric plexus as well, thus completely denervat-
ing the large bowel of its sympathetic control. In moderately severe cases
it is found that spontaneous emptying of the colon occurs one day postoperatively and is a regular daily occurrence from then on. In more difficult
cases the colon may need the assistance of cathartics, flushings and oil
retention enemata, or even occasional doses of acetylcholine or eserine for
a time. These measures are discontinued as the colon regains its own function. Vasodilation occurs in the feet of both sexes following this operation
but is found of no inconvenience. In male patients it should be remembered
again that the ejaculatory function of the prostate and seminal vesicles are
interfered with as a result of the presacral neurectomy portion of the
operation.
Dysmenorrhoea.—Although the relation of the presacral nerve to dysmenorrhoea was recognized in France many years ago, it is only of recent
date in England and America that serious consideration has been given to
presacral neurectomy for the relief of menstrual pain. It was Leriche who
placed the operation on a firm scientific footing by his periarterial sympathectomy. But it remained for Cotte to establish the procedure beyond all
question in the surgical armamentarium of the gynaecologist. The operation
as it is carried out today is essentially Cotte's modification of Leriche's idea,
that is, resection of the superior hypogastric plexus supplanting the combined periarterial sympathectomy and presacral neurectomy. In 1927 Cotte
published a report of 90 successful cases of dysmenorrhoea treated by
resection of the presacral nerve. In 1929 he reported over 200 such cases
having had satisfactory results. Fontaine and Herrmann record excellent
results in 13 out of some 15 cases so treated. These were followed over a
considerable period post-operatively and report no relapse. Similar results
are now forthcoming in England. In a Hunterian lecture in 1934, Davis
reported some 20 cases he had done since 1932. In America, De Courcy in
1934 reports 21 cases in which he claims 100% cure of the previous pain.
Adson and Masson last year reported 6 cases from the Mayo Clinic and later
Craig and Counsellor have added another 8 cases to this list. It always
struck me, during my time in Rochester, as an odd thing how slowly a new
Page 179
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operation is absorbed into an old regime. The neurosurgeons were resecting
the presacral nerve for Hirschsprung's disease and acquired megacolon and
for vesical dysfunction for several years before it was applied in gynaecological work, in spite of the continued reports from France. However, it
appears to be accepted generally now not only without untoward effects
but with reports of high degrees of success. .
Cotte in 192 5 gave the indications for the operation as follows:
1. Pelvic neuralgia.
2. Vaginismus.
3. Dysmenorrhoea, resistant to other treatments.
4. Metrorrhagia of ovarian origin.
In addition to the above conditions, the operation has been used in
pruritis vulvae and perinealis, disturbances of genital sensibility, ovaritis
sclero-cystica, leucorrhcea and hydrorrhcea, and for pain from inoperable
carcinoma of the uterus and pelvic organs. It is difficult to obtain reports
in sufficient numbers to evaluate properly the results of the operation in so
many conditions. For the present its application to dysmenorrhceas will
suffice.
The dysmenorrhceas have been divided by Counsellor into two types,
an essential or primary dysmenorrhoea, and secondly, dysmenorrhoea secondary to some demonstrable pelvic lesion such as uterine displacements,
myomata, endometriosis, salpingitis or ovarian tumours. Adequate gynaecological surgery usually corrects this latter type. It is primary dysmenorrhoea that we are chiefly concerned with at this time, a type in which the
pelvic organs have a normal appearance and are independent of pathological
changes, though the two may sometimes be associated. Its cause is still a
matter of dispute and many theories have been advanced, such as the
retention of menstrual blood in the uterus due to mal-positions of the body,
with consequent uterine contractions in an attempt to empty itself. Others
have advanced the hypothesis that uterine hypoplasia is a prominent factor.
The infantile type of uterus is composed of twice as much connective tissue
as muscle tissue. It is known that the infantile type occasionally is found
to persist after puberty. Hence arises the theory that with the hyperaemia
of menstruation there is engorgement of the vessels, with stagnation of the
blood due to an inadequate musculature and a resulting pressure upon the
uterine nerves. Counsellor objects to this hypothesis on the grounds that
in many of these primary dysmenorrhceas the uterus is of normal size and
consistency. He therefore feels that the condition is an acquired dysfunction and claims that in 5 0% of his cases his patients gave a history of
normal flow for years following puberty before the dysmenorrhoea began.
There is also the question of endocrine disturbance and especially the findings of Novak and Reynolds who showed that the rhythmic contractions
are the result of the ovarian follicular hormone. They suggest that primary
dysmenorrhoea is due to spasmodic uterine contractions resulting from an
imbalance in the action of corpus luteum, folliculin and progestin. Whatever the intrinsic effect of these hormones upon the uterine musculature, it
is a common observation that applications of heat tend to relieve the spasm
and pain. It has been noted also by some women that alcohol exerts the
same effect. The physiological action of both these agents is one of vasodilatation. This painful condition therefore suggests not so much a hyperaemia and congestion as some have stated as a vaso-spastic disorder perhaps
resembling the Raynaud's syndrome. Hence section of the presacral nerve
which carries vaso-constrictor fibres to this organ would naturally be
expected to relieve the condition.
Page 180 The neurogenic control of the uterus is still uncertain. In 1895, Langly
showed the centre in the cord controlling contractions of the uterus of the
rabbit lay between the 10th D and the 2nd L segments. In 193 3 Cleland
showed by using paravestebral anaesthesia afferent fibres in the human
entered the cord by the 11th and 12 th D roots only. Findings differ as to
the functions played by the sympathetic and parasympathetic systems upon
the organ. Dahl states that their actions are the reverse of those found in
the bladder, that is, the sympathetic is motor to uterine contracions while
the parasympathetic is inhibitory to the same muscles. Hoffman makes the
inervation more complicated and claims that the sympathetic is motor to
the circular muscle fibres while the longtudinal fibres are excited by the
parasympathetic; also that the former nerves relax the cervix uteri while
the nervi erigentes cause it to close. In a later paper Dahl suggests that the
sympathetic becomes motor to the uterus during pregnancy, a suggestion
that is hardly tenable in the light of more modern knowledge that parturition
takes place normally after section of the presacral nerve. On the other
hand Gutsmann showed that neither section nor complete destruction of
the sacral cord will prevent parturition, though it does make it necessary
to apply forceps when the head reaches the pelvic floor. According to Rein
there is spontaneous birth in rabbits after a complete denervation of the
uterus. It is therefore seen that not only is the problem of the neuro-muscu-
lar mechanism of the uterus very involved but few indisputable facts are
known about it.
The operative technique of presacral neurectomy consists of a low abdominal incision similar to that used for any pelvic laparatomy. With the
patient in Trendelenburg position, the intestines are packed off to expose the
bifurcation of the aorta and the promontory of the sacrum. Before disturbing
the posterior parietal peritoneum the hypogastric plexus may be seen plainly
in the interiliac trigone. The peritoneum over this area is then incised longitudinally for about 8 cm. from the bifurcation of the aorta down over the
sacral promontory into the pelvis. It is then elevated bilaterally and the
nerve beneath it is isolated and dissected from its bed. Care must be taken
to include the branches from the 2nd, 3rd and 4th paravertebral lumbar
sympathetic ganglia. The dissection must be carried far enough into the
pelvis to visualize the bifurcation of the superior hypogastric plexus into
the two hypogastric nerves before it is excised. When this is accomplished
the denervation is complete and the peritoneum is closed by fine catgut
suture.  The anterior closure is made in the usual manner.
Because primary dysmenorrhoea is found in association with other
gynaecological conditions, though quite independent from the latter, most
writers advise the usual pelvic repairs and procedures in conjunction with
the operation for presacral neurectomy. In Cotte's large series he demonstrated that the relief of pain is more complete when the necessary uterine
suspensions and removal of chronically infected tubes are effected. It is the
common practice to repair these lesions before proceeding with the sympathectomy.
The immediate effects of the operation seem to produce a spurious
mensis within the first 48 to 72 hours no matter what time of the menstrual
cycle the operation is performed. The following period is related in point
of time to the last preoperative period. Subsequent periods are normal in
time and amount of flow as a general rule. There are slightly varying
reports on the success of the operation but it is only very occasionally that
no benefit is recorded. In such cases a legitimate criticism would throw
doubt on the completeness of the neurectomy.  On the whole those surgeons
Page 181
B
.t\«
m who began the operation far enough back to possess worth-while follow-up
records are most enthusiastic about their results. Cotte reports that one
of his cases, now six and one-half years postoperative, has not only had no
return of her dysmenorrhoea but has gone through a normal pregnancy
terminated by a normal delivery. Normal pregnancies are reported by the
same author following the operation in three other cases, proving that the
procedure does not impair the normal function of parturition. American
surgeons report the same good results but having taken up the operation at
a more recent date are unable to add any data regarding pregnancies in their
series.
There is still another major application of presacral neurectomy which
is rapidly gaining favor due to the success of the results reported. I refer
to its use in cases of inoperable carcinoma of the pelvic organs. Fontaine
and Herrman cite many French writers who have had considerable experience with the relief of pain gained by this procedure. Some of these report
excellent results from section of the superior hypogastric plexus alone. But
according to Prof. Leriche it is advisable to do a complete pelvic sympathectomy after which one can be quite sure of complete relief from the most
intolerable pelvic pains. Fontaine goes so far as to state, "We believe that
it is superior to cordotomy, since it gives complete relief from pain without
sacrificing any of the normal protective reflex pathways of the individual."
The above account of the presacral neurectomy is a brief review of the
conditions in which the operation is found to be applicable. No doubt other
uses will be discovered to be added to its already broad and ever widening
scope. Its popularity as indicated by the rapidly increasing volume of literature on the subject appears to be due to three main factors; the low operative risk, the absence of any deleterious effect upon normal organs, and
lastly its positive beneficial influence on a variety of pathological lesions and
physiological dysfunctions in properly selected cases.
THE CANCER PROBLEM
[The following extract from an address given by Dr. C. F. Martin, Dean of
the Medical Faculty of McGill, is of special interest at this time, and will repay
careful consideration and thought by members of the medical profession.—Ed.]
The message is a simple one. I have stressed the need of early diagnosis
and early treatment. I have emphasized the importance of publicity. "Fight
cancer with knowledge" is a familiar slogan—knowledge by the public and
by the profession. The price of protection and control is organization for
service and for research, and the greater of these for us in Canada is service.
The service must be nation-wide in scope through the establishment of
cancer centres or clinics, and groups organized to afford every facility for
the care of cancer patients. These centres are the pivotal units, the foci to
which patients will be attracted through publicity and through successful
results; the centres of attraction to which patients and physicians will come
for the solution of any of the problems connected with this dread disease—
centres strategically distributed throughout the country. In the larger
cities such clinics, preferably in association with the hospitals and universities, fully equipped to fulfil all the needs of diagnoses and surgical treatment, and with modern installation for radiological care. In the smaller
communities simpler clinics for diagnoses and less elaborate treatments may
be carried out. Most of all should such centres be a stimulus and assistance
to the family physician, whose position in the cancer problem will always
be unique. He it is who first sees the patient, he it is who guides the family,
Page 182 and on him devolves the main responsibility for that early attention which,
if rightly directed, leads to health and happiness, or, if wrongly, to misery
and destruction.
A survey of the situation leads to the indisputable conclusion that the
care of cancer patients requires special training. Nor is it the job of any one
man alone—nothing but a co-ordinated personnel will make the perfect
attack. The diagnosis and treatment of any cancer is not always a simple
matter, and often calls for the combined effort of the surgeon, the physician
and the specialist, the pathologist and the radiologist. A co-operative effort
on the group system, alone fulfils the ideal need of cancer care.
We do not require new buildings or elaborate new construction. The
existing centres merely await financial aid to render them more efficient,
but everywhere the service requires organization, without which no perfect
care can be afforded.
Co-ordination is absolutely essential, and unselfish collaboration, with
but one end in view—service to humanity.
Turn your eyes to Sweden for the perfect system under government
control, where suspects of cancer are brought to early attention in cancer
centres, where the diagnoses are established with a commendable rapidity,
and where each patient is followed up by a system which includes the
services of the post office, the priest and the police.
The medical profession in tlx attack, on cancer cannot afford to be individualistic s.
Success depends on the organized collaboration of all the forces of
society.   Anti-cancer leagues have achieved remarkable results  in other
Vain and Fever Readily Respond to
PULVETS
PHENALONE with CODEINE
HARTZ
IN CASES of Neuralgias, Rheumatism, Myalgias, Lumbago, Influenza, Tonsillitis, and other similar affections,
it is important that the treatment prescribed have no disagreeable digestive after effects.
Pulvets PHENALONE with CODEINE are Analgesic, Antirheumatic and Antipyretic in action . . . they readily
relieve pain and reduce fever . . . without disturbing the
digestive function.
Each pulvet represents five grains of PHENALONE combined with one-sixth grain of CODEINE PHOSPHATE.
Dose—One to two pulvets every two or three hours as indicated.
Best results are obtained by the exhibition pf the dosage half
an hour before or not less than two hours after the ingestion
of food.
Fill in and mail the coupon for clinical sample.
The J. F. HARTZ CO. Limited
TORONTO
Phamtacetitical Manufacturers
MONTREAL
The J. F. Hartz Co., Limited, Toronto, Canada. V.
Gentlemen: Please send clinical sample MIS1URA TUSSI Hartz.
Dr. 	
Street    City 	
>m
hi.  j
Page 183 countries. Why not then with us?—as a national undertaking and under
the wonderful inspiration of this Silver Jubilee Year.
In consideration of this Silver Jubilee campaign, it would seem important
that organization of these clinics on a national basis is a fundamental necessity, their standardization and their control by competent authorities. It is
equally important that due publicity should be given to their existence, to
their facilities and to the opportunities they can offer for the treatment of
cancer.
In the outlying districts means of access to these centres may not be easy
for indigent patients, and it is hoped that some form of transportation
facility may be provided to render them of sufficient usefulness.
S. BOWELL & SON
DISTINCTIVE  FUNERAL
SERVICE
Phone 993
66 SIXTH STREET
NEW WESTMINSTER, B. C.
• To enable the physician to
fit the treatment to the
particular need of the
patient, the five types of
Petrolagar afford a range of
laxative potency which will
meet practically every
requirement of successful
bowel management.
Samples free on request
Petrolagar Laboratories of Canada, Ltd.
Walkerville, Ontario
Petirolaqair
«a«ft for CONSTIPATION
Distinctive
PRINTING
CARDS
STATIONERY
that really are nicer
AND COST YOU
NO MORE
ROY
WRIGLEY
Limited
300 WEST
PENDER STREET
VANCOUVER, B. C.
Page 184 ik
illlfi§i
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tfce
^CtCe7ta^ VrtHe «^1, me
io*c
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dies
oi
fcody
cow
flaf»*
oi
reSV"eases
<* **£ aciA°s\Yciiott* d'8 cyc^c
^ottt^^'d ^er    tied** ** «   a^a»-
ft**1* *L*\e e«et: oi i©**
a
a
"HUPp
111
>* 11
'if
i   ;
WM. R.WARNER 6 CO.
I    M    I
727 KING STREET, WEST,
TORONTO, ONTARIO
i
M
!>
I 1 Need of Calcium
A VIGOROUS body requires a strong, bony
. skeleton as a basis for its activity. The building of such a skeleton calls for considerable quantities of calcium.
Nature provides this material in the outer covering of the
grains and in the woody portion of the plants, but these are
usually rejected in providing modern food. As a result the
modern diet tends to be deficient in minerals. This need is being
met in part by the increasing use of raw vegetables in salads
for the adult but these are not available to small children.
In addition to leafy vegetables about the only source of
calcium and phosphorus is milk. Milk of cows carries about
one-third more calcium than does human milk.
By 1920 Doctor H. C. Sherman had satisfied himself that
the ordinary diet was so lacking in calcium that during pregnancy of women the intake in the diet was not equal to the
demands on the body. Likewise, the supply was not sufficient
in many diets to meet the needs of the growing child. The
recognition of this widespread need was an important factor in
quickening his interest in the part which milk might play in
nutrition.
In 1922 he reported a careful study of the nutrition of
children in which there appeared the following:
"In view of the results obtained with different foods as sources
of calcium it is desirable also to emphasize the importance of a quart
of milk per day for every child, and it -would be best to maintain this
level of milk intake up to at least the age of 12 to 14 years."
ASSOCIATED DAIRIES
LIMITED
DISTRIBUTING
RICH—SAFE—CLEAN—MILK
Fairmont 1000
service phones:
North 122     New Westminster 1445 m
rik^t
/
HI     WHAT DOES ONE
OF THESE  BREAKFASTS LACK?
THE breakfast at the left contains very little "bulk"—
needed to help promote proper elimination.   Yet this
type of meal is eaten every morning in thousands of homes.
Fruits and vegetables — and bran — are the best sources
of "bulk." But tests show that certain individuals have
much of the fiber of fruits and vegetables broken down in
the alimentary tract. When bran is added to their diet,
elimination becomes regular again.
Laboratory investigations indicate that bran is a safe
laxative food for the average person. Microscopic examination of the intestines of bran-fed laboratory animals, over a
period corresponding to 30 years of human life, failed to
show any sign of injury to the intestinal tract.
Special processes of cooking and flavoring make Kellogg's
All-Bran finer, softer, more palatable. Except in cases o£
individuals who suffer from intestinal conditions where any
form of "bulk" would be inadvisable, All-Bran may be used
with safety.
This delicious cereal is likewise a good source of vitamin
B and iron. Your patients may enjoy All-Bran either as a
cereal or in cooked dishes. Sold by all grocers in the red-
and-green package.   Made by Kellogg in London, Ontario.
i! 3BD3&B3SSI
A new type of bismuth salts has recently appeared in the field of therapeutics:
the oil-soluble salts for intramuscular injection. These constitute a class of
products which are rapidly absorbed due to the fact that the bismuth derivative
dissolves immediately in the lipoids and does not have to be transformed in situ.
Ever anxious to meet all the requirements of the Medical Profession, we are now
offering, under the trade name of NEOCARDYL, a compound representative of
this new form of liposoluble bismuth. NEOCARDYL has an additional decided
advantage over other compounds of its class in that it contains bivalent
sulphur combined in its molecule.
NEOCARDYL   I
"POULENC"
Ampoules of 1.5 cc. equivalent to 0.075 Gm. of bismuth metal.
Boxes of 12, 50 and 100 ampoules; bottles of 30 cc.
LABORATORY POULENC FRERES
OF CANADA LIMITED
Distributors: ROUGIER FRERES, MONTREAL
A PRESCRIPTION SERVICE . . .
Conducted in accord with the ethics of the Medical
Profession and maintained to the standard suggested by
our slogan:
Pharmaceutical Excellence
McGi  6 Ofmr,
FORT STREET (opp. Times)      Phone Garden 1196      VICTORIA, B. C.
STEVENS' SAFETY PACKAGE
STERILE GAUZE
is a handy, convenient, clean commodity for the bag or the office.  Supplied
in one yard, five yards and twenty-five yard packages.
B. C. STEVENS CO.
Phone Seymour 698
73 0 Richards St., Vancouver, B. C. WHEN Diathermy, Radiant Heat, Galvanic Current, or other physiotherapeutic measures are applied in such conditions as
diseases of the pelvic organs, the genito-urinary
tract, rheumatism, etc., they should be followed
up with correct after-treatment.
Antiphlogistine may advantageously be employed
as an adjuvant in the majority of such cases, not
only on account of its synergistic powers to sustain heat within the tissues, but because of its
soothing, antipruritic, decongestive and protective qualities when applied to erythematous, erosive, indurated and painful surfaces.
Sample and Literature on Request
ANTIPHLOGISTINE
Made in Canada
The Denver Chemical Mfg. Co,
153 Lagauchetiere Street W.
MONTREAL 2559 Cambie Street
Nitttn $c atynmamt
ancouver
, B. C.
Portable   X-Ray  Work   Now   Possible
IN THE HOME
A Convenience to All Doctors.   Totally Efficient and Shock Proof
For full details, phone or write
W. C. ECCLES
X-Ray Department, St. Paul's Hospital, Vancouver, B. C.
■  REST HAVEN -j
A Medical Institution for the restoration of health,
situated eighteen miles from Victoria, overlooking the
Gulf of Georgia.
Modern facilities for the treatment of all classes of
patients with the exception of those suffering from
mental or contagious diseases. Hydrotherapy, electrotherapy, massage, and diet, under medical supervision.
Physicians referring patients or convalescents for
treatment are requested to send such reports and suggestions as may assist in their treatment.
REST HAVEN SANITARIUM
and  HOSPITAL
SIDNEY, B. C. Coramine "Ciba
yj
A non-toxic circulatory and respiratory stimulant for oral, hypodermic, intravenous and
intracardiac administration.
Improves the pulse and blood pressure, reinforces the contractions of the myocardium.
Very wide margin of safety (1-15 cc.)
AMPOULES LIQUID
CIBA COMPANY LIMITED
MONTREAL
flfoount pleasant tanbertaking Co. ILtb-
KINGSWAY at 11th AVE. Telephone Fairmont 58 VANCOUVER, B. C
R. F. HARRISON W. R. REYNOLDS K W
V
• r it
I.   41
».■
|Ni
I'
A Poor Scholar ... il
because of a Poor Breakfast
Many a child is scolded for dullness when he should be treated for undernourisl
ment. In hundreds of homes a "continental breakfast'' of a roll and coffeeistl
rule. If, day after day, a child breaks the night's fast of twelve hours on this scan
fare, small wonder that he is listless, nervous, or stupid at school.
Pablum offers a happy solution to the problem of the school-child's breakfasl
Mothers who learn about Pablum from their physicians are delighted to serve it fo
it needs no cooking and can be prepared in a minute at the table—more quicH
than many less nourishing foods. Pablum not only ends the bane of long cooking (
cereals but in addition furnishes a variety of minerals (calcium, phosphorus, iron, an
copper) and vitamins (A, B, G, and E) not found so abundantly in any other cerea
PABLUM is rich in calcium and iron,
minerals likely to be deficient in the
school-child's diet yet needed in more
than average amounts during childhood.
Pablum is 6 times richer than fluid milk
in calcium and contains 10 times more
iron than does spinach. It also furnishes
generous amounts of vitamins B and G,
essential for normal appetite. Unlike
other cereals, Pablum is base-forming,
important because the growing child
needs to store alkali. The nutritional
value of Pablum is attested in studies by
Crimm et al who found that tuberculous
children receiving supplements of Pablum showed greater weight-gain, greater
increase in hemoglobin, and higher
serum-calcium values than a control
group fed farina. Reprint sent on request of physicians. Mead Johnson i
Co. of Canada, Ltd., Belleville, Ont.
Pablum (Mead's Cereal pre-cooked) is a pafc
able cereal enriched with vitamin- and minen.1
containing foods, consisting of wheatmeal, oatmeal, cornmeal, wheat embryo, alfalfa le
beef bone, brewers' yeast, and sodium chloridi
1 OMMY, that's the third time this week
haven't learned your lesson. Why don't you listen
to me when I tell you how to work the problems?"
Please enclose professional card when requesting samples of Mead Johnson products to cooperate In preventing their reaching unauthorized!* The Most Economical Remedy for
HAY FEVER SUFFERERS
Parke, Davis & Co. POLLEN EXTRACT
$9.45
Complete
Treatment
Two Other Quality Lines Always Available Here
ADHESIVE PLASTER
BANDAGES      ::     COTTON
by
JOHNSON & JOHNSON
fjrfSEY-IOSO
W OMHAU.
jH MIGHT
Complete Stocks of
ROUGIER FRERES
and
ANGLO-FRENCH Specialties
OPEN
ALL
NIGHT
GEORGIA PHARMACY
SEYMOUR
1050
W. GEORGIA
STRE E T
<£mtn $c ijatma Htfr
Established 189}
VANCOUVER, B. C.
North Vancouver, B. C.     Powell River, B. C.
published Monthly at Vancouver, b. C by ROY WRIOLEY LTD.. 300 West Pender Street OBBBi
^^^^^•^^^^^^P^g^g^jja^^^^^^i^
t\ \\
V   IF , !■■
K li.:
I; M
m K
$ Yf
h
v
Hollywood Sanitarium
Limited
For the treatment of
Alcoholic, Nervous and Psychopathic Cases
Exclusively
Reference—B. C. Medical Association
For information apply to
Medical Superintendent, New Westminster, B. C.
or 51S Birks Building, Vancouver
Seymour 4183
Westminster 2 8* 8
SS^SSSSSSSSSSS^^SSSSS^SSS

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